Preparing for Infectious Diseases, Natural Disasters and Terrorist Attacks

Ever since two airliners crashed into the Twin Towers on Sept. 11, 2001, the United States has invested billions to prepare for subsequent threats and public health emergencies: infectious diseases, natural disasters and perhaps terrorist attacks using bioweapons.

Yet there has been no national-level, comprehensive review of the evidence for public health emergency preparedness and response (PHEPR) practices. Recognizing this deficiency, the Centers for Disease Control and Prevention (CDC) went to the National Academies of Sciences, Engineering and Medicine three years ago and asked them to convene a national panel of public health experts to review the evidence for emergency preparedness and response.

The committee members, who include Stanford Health Policy Director Douglas K. Owens, didn’t mince words: “The science underlying the nation’s system of response to public health emergencies is seriously deficient, hampering the nation’s ability to respond to emergencies most effectively to save lives and preserve well-being.”

The committee issued its findings July 14 with a report at a Zoom conference.

“Evidence for public health preparedness and response comes from a complex mix of studies and observations, often making conclusions about effectiveness of specific practices challenging or impossible,” said Owens. “There was no established method for understanding the strength or weakness of the evidence with regard to public emergency preparedness and responses.”

The committee spent three years, consulting experts with the National Transportation Safety Board, NASA, FEMA, and dozens of public health agencies from around the country, Puerto Rico as well as Native American health community leaders.

The 20-member committee reviewed evidence for PHEPR generated since the 9/11 terrorist attacks, including published literature and publicly available reports, randomized trials, observational and modeling studies. They also asked for public input at information-gathering sessions to establish a methodology applicable across the full range of PHEPR practices.

The resulting report, Evidence-Based Practice for Public Health Emergency Preparedness and Response, presents recommendations intended to transform the infrastructure, funding and methods of PHEPR research. Some of those include:

• Appoint a Public Health Emergency Preparedness and Response (PHEPR) evidence-based guidelines group;
• Establish infrastructure to support ongoing PHEPR reviews;
• Develop a national PHEPR science framework;
• Ensure infrastructure and funding to support PHEPR research
• And ensure the translation, dissemination and implementation of PHEPR research.

“The evidence base for public health emergency preparedness and response was not comprehensive,” said Suzet M. McKinney, the CEO and Executive Director of the Illinois Medical District. “We really saw a series of one-off studies, limited by one topic or one specific disaster, rather than a more comprehensive approach across jurisdictions, across disaster events and across agencies.”

One of the committee’s main recommendations is that the CDC establish an independent organization to develop PHEPR recommendations, similar to the U.S. Preventive Services Task Force. That national body of experts makes evidence-based, graded recommendations to clinicians on preventive services that are widely followed nationwide.

“Think of the task force,” said Owens, immediate past chair of the health-care body. “We have very comprehensive evidence reviews that rate the strength of the evidence with methods that are very well established for medical interventions. But the evidence grading systems aren’t adequate to evaluate the complex evidence for public health emergency preparedness, so much of our work was to develop an evidence grading system for public health emergencies.”

What About COVID-19?

The committee’s work began long before the global COVID-19 pandemic, however they do address it in final their report:

“Although our reviews were not conducted in response to the COVID-19 pandemic, the likely applicability of many of our findings is noteworthy,” the authors wrote. “For example, while it is too soon to conclude definitely whether quarantine is effective at reducing and stopping transmission of this novel coronavirus, the findings from the qualitative evidence synthesis regarding the psychological and financial harms of this practice will undoubtedly be just as relevant to the current quarantine experiences as they are to past outbreak scenarios.”

A question was asked during the Zoom call about whether the United States might have been better prepared for COVID-19 had the committee’s recommended task force been in place.

“The real crisis that we are living in as public health practitioners today really amplifies the need for a system that allows us to have a positive impact in a systematic way,” said Francisco Garcia, chief medical officer of Pima County in Tucson, AZ. “The timing is serendipitous and tragic.”